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Cranfield Surgery, 137 High Street, Cranfield, Bedford MK43 0HZ

Tel: 01234 750234 Marston Surgery, 59 Bedford Road, Marston Moretaine, Bedford MK43 0LA

Tel: 01234 766551

CRANFIELD & MARSTON SURGERY - NEW PATIENT INFORMATION

Your named, accountable GP is Dr Ismail – please note you are able to see any of our clinicians.

To ensure completeness of your registration records please return this form to the surgery as soon as possible. Thank you

Surname……………………………………………….................................. Date……………..……………………………

First Name(s)………………………………………………………………………….........................................................

Full Address……………………………….…………………………………………………………………………………………….…..

…………………………………………………………………………… Postcode………………………………..…..

Tel No (Home) ……………...…………. (Work)…………………………… Mobile No …………………………….………

By giving us your contact phone numbers you agree to the Practice contacting you by phone. Please let the practice know if you change your number or if the phone is lost or stolen.

Do you consent to receiving text messages from the Practice Yes No

Email address ………………………….………………………………………………………………………………………..…….…..

Marital Status…………………..…..…… Date of Birth ………………………….. Sex…………………………..…….…

Next of Kin ……………………..………………….. Relationship …………………… Contact No ……..……..……..

Children Under 16 – Please give parent/guardian name ………………………Contact No……………..……

We will only contact your next of kin in the case of an emergency

If you are a student at Cranfield University please give leaving date…………………………………………..

Veteran Status – have you served in the British Armed forces for more than one day Yes / No

Ethnic Origin – please tick as appropriate

First Language - please tick as appropriate

British/Mixed British Caribbean

Irish African

Other White Asian

Indian Pakistani

Chinese Other Please indicate…………………………….

English Other Please Indicate……………………………..

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CARER DETAILS

Are you a carer? ............................................... Does a carer look after you? ……………………………..

Carer’s Name……………………………………………….. Carer’s Address .………………………………………………..

..………………………………………………………………….. Contact No……………………………………………….………..

Please complete carers form if applicable. Form available from Reception

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GENERAL MEDICAL HISTORY

Weight…………………………….kg Height…………………..……cm Waist Measurement*………….………cm

*To find your true waist, feel for your hip bone on one side of your body. Move upwards until you can feel the bones of your bottom rib. Halfway between is your

waist. For most people this is where their tummy button is.

Blood Pressure…………..................................…… (To be taken by the Nurse at your check up)

Diet (please give details of any special dietary requirements, eg, vegetarian, gluten free, etc)

……………………………………………………………………………………………………………………………………………………….

Exercise (number of 30 minutes sessions per week) .........................................

Smoking Status Please tick Smoker Ex Smoker Never Smoked

How much tobacco or cigarettes do you smoke? Number of Cigarettes per day ………..…………

Ounces of Tobacco per week ………..…………..

Alcohol questionnaire – please complete the attached alcohol questionnaire and return it with this form.

Please give details of any medical conditions including dates

Asthma/COPD Date of Onset ………………………………………………………….

Diabetes Date of Onset ………………………………………………………….

Heart Problem Date of Onset ………………………………………………………….

Stroke Date of Onset ………………………………………………………….

Epilepsy Date of Onset ………………………………………………………….

Cancer Date of Onset ………………………………………………………….

Hypertension Date of Onset ………………………………………………………….

Depression/Mental Illness Date of Onset ………………………………………………………….

Have you ever suffered with depression or anxiety? …………………………………………………..

Have you received any treatment for depression or anxiety? ..........................................

If yes, what treatment have you received…………………..……………………………………………….

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DISABILITIES (visual, hearing, communication needs etc – please specify) & PHOBIAS - Please give

details of any other disabilities you wish to make us aware of including date of onset

1. ……………………………………………………………….. Date of Onset ………………..………………………………

2. ……………………………………………………………….. Date of Onset …………….…..……………………………

3. ……………………………………………………………….. Date of Onset …………………………………………………

OTHER CONDITIONS - Please give details of any other conditions including date of onset

1. ……………………………………………………………….. Date of Onset ………………..………………………………

2. ……………………………………………………………….. Date of Onset …………….…..……………………………

3. ……………………………………………………………….. Date of Onset …………………………………………………

OPERATIONS - Please give details of any operations including dates

1. ……………………………………………………………….. Date ……………………..……….………………………………

2. ………………………………………………………………. Date ……………………………….………………………………

3. ………………………………………………………………. Date …………………………………….…………………………

CURRENT MEDICATION - Please list current medications together with dosage or attach repeat

prescription sheet

1. ................................................................ 5. ……………………………………………………..…………….

2. …………………………………………..... 6. ……………………………………………….

3. ……………………………………………. 7. ………………………………………………..

4. ……………………………………………. 8. …………………………………………………………………….

Please indicate where you wish to collect your prescriptions from:

Cranfield Surgery Cranfield Chemist Marston Surgery Marston Chemist

Other (please specify)………………………………………………………………………………………………………………………………

ALLERGIES - Please list any allergies & reaction to allergy

1. …………………………………………………… Mild Moderate Severe Anaphylaxis

2. …………………………………………………… Mild Moderate Severe Anaphylaxis

3. No known Allergies

FAMILY HISTORY

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If any of your blood relatives have had any of the following conditions please tick the appropriate box and indicate the date of onset of the condition and their relationship to you eg, parents,

grandparents, brother, sister etc

Heart Attack Relation……………………………… Date of onset…………………….. Cancer Relation……………………………… Date of Onset…………………….. Diabetes Relation……………………………… Date of Onset…………………….. High Blood Pressure Relation……………………………… Date of Onset…………………….. High Cholesterol Relation……………………………… Date of Onset…………………….. Asthma Relation……………………………… Date of Onset…………………….. Tuberculosis Relation……………………………… Date of Onset…………………….. Stroke Relation……………………………… Date of Onset…………………….. Coronary Heart Disease Relation………………..……………

Under 60 yrs Over 60 yrs Date of Onset……………………..

Other - please indicate Relation……………………………… Date of Onset……………………. VACCINATIONS

Date of Last Tetanus ……………………………………….………………………………………………………………….

Date of MMR ………………………………………………………………….……………………………………….

Date of Meningitis C ……………………………………………………………………………………………………………

Dates of Other Vaccinations (eg, HepA, HepB etc)

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

FAMILY DETAILS How many children do you have? …………………......……… Please give ages………………………..……………

FOR FEMALES ONLY

Which method of contraception are you using at present? …………….................................................

When was your last cervical screening within the UK? ………………………………………

Do you regularly self-examine breasts*? Yes No

* Please see leaflet on website

FOR MALES ONLY

Do you regularly self-examine testicles*? Yes No

* Please see leaflet on website

Patient Signature …………………………………………………….…..

Date …………………………………………….………

To be completed by all patients aged 16 years and over

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Childhood Immunisation Programme

To be completed for all children under 16 years of age Name …………………………………………………………………………………............. Address ……………………………………………………………………………………….. …………………………………………………… Postcode ………………………………… Date of Birth …………………………………………………………………………………...

At what age to immunise

Diseases protected against Date given

Two months old

Diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type b (Hib)

Pneumococcal infection

Rotavirus (Oral)

Meningitis B

Three months old

Diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b (Hib)

Meningitis C (meningococcal group C)

Rotavirus (Oral)

Four months old

Diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b (Hib)

Pneumococcal infection

Meningitis B

Between 12 and 13 months old

Haemophilus influenzae type b (Hib) Meningitis C

Measles, mumps and rubella (German measles)

Pneumococcal infection

Meningitis B booster

Three years and four months or soon after

Diphtheria, tetanus, pertussis and polio

Measles, mumps and rubella

Girls aged 12 to 13 years Cervical cancer caused by human papillomavirus types 16 and 18

13 to 18 years old Tetanus, diphtheria and polio

Meningitis C

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Introduction to Summary Care Records

Today, records are kept in all the places where you receive care. These places can usually only share information from your records by letter, email, fax or phone. At times, this can slow down treatment and sometimes make it hard to access information.

Summary Care Records are being introduced to improve the safety and quality of patient care. Because the Summary Care Record is an electronic record, it will give healthcare staff faster, easier access to essential information about you, and help to give you safe treatment during an emergency or when your GP surgery is closed.

For example, a person who lives in London is on holiday in Brighton. One evening, they're knocked unconscious in a car accident and taken to an accident and emergency (A&E) department. Under the current system of storing health records, it would be difficult for A&E staff to find out whether there are any important factors to consider when treating the person (such as any serious allergies to medications), especially as their GP surgery is likely to be closed. If healthcare staff cannot get the relevant health information quickly, some patients may be at risk.

A Summary Care Record is an electronic record that's stored at a central location. As the name suggests, the record will not contain detailed information about your medical history, but will only contain important health information, such as:

whether you're taking any prescription medication

whether you have any allergies

whether you've previously had a bad reaction to any medication

Access to your Summary Care Record will be strictly controlled. The only people who can see the information will be healthcare staff directly involved in your care who have a special smartcard and access number (like a chip-and-pin credit card).

Healthcare staff will ask your permission every time they need to look at your Summary Care Record. If they cannot ask you, e.g. because you're unconscious, healthcare staff may look at your record without asking you. If they have to do this, they will make a note on your record.

Do I have to have a Summary Care Record?

You can choose to have a Summary Care Record. If you would like one, you won't need to do anything. It will happen automatically.

You can choose not to have a Summary Care Record. Let your GP surgery know by filling in and returning the opt-out form overleaf.

More information about Summary Care Records is available at www.nhscarerecords.nhs.uk

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Online Access

You can now use the internet to book appointments with a GP, request repeat prescriptions and look

at your medical record online. You can still use the telephone or call in to the surgery for these

services as well.

As this is access to sensitive information, you will be required to apply for access to this service and

offer proof of who you are. You will be given login details and you will then be able to use the links

on our website to manage your appointments and prescriptions. You can even download the App

for your smartphone.

To apply for online access, please complete the application form below and bring it to the surgery

along with proof of your identity. A copy of the form is also available from reception. If you wish

to request access to a third party record please ask at Reception.

Cranfield & Marston Surgery

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Application for online access to my medical record

I wish to have access to the following online services (please tick all that apply):

Booking appointments

Requesting repeat prescriptions

Accessing my summary medical record

Accessing my detailed coded record

I wish to access my medical record online and understand and agree with each statement (tick)

1. I have read and understood the information leaflet provided by the practice

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, this is at my own risk

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

You will be asked to provide proof two forms of identity, one photo ID and one proof of

your address.

Signature Date

For practice use only Patient NHS number

Identity verified by (initials)

Date Method Vouching Vouching with information in record

Photo ID and proof of residence ID: Driving licence Passport

Bank statement

Authorised by Date

Date account created

Date passphrase sent

Level of record access enabled Prospective

Retrospective

Notes / explanation

Surname Date of birth

First name

Address Postcode

Email address

Telephone number Mobile number

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Cranfield University Latent TB Infection (LTBI)

Screening

Cranfield & Marston Surgery are taking part in TB Screening to offer screening to all eligible

patients. Please complete and return the form below. If you are eligible for screening you will

be sent a letter to arrange an appointment for a blood test.

Name ___________________________________

Date of Birth ___/___/______

NHS Number ______________

Gender Male Female

1. Have you ever been treated for TB in the past? Yes No

(Please note those who have been treated for TB previously are NOT eligible for

inclusion)

2. Age _____ years

(Only those aged between 16-35 years are eligible for inclusion)

3. Country of birth ………………………………………………………..

(Please see the list of countries overleaf for eligibility)

4. Year of entry to the UK ______

(Only those who have been in the UK for less than 5 years are eligible for

inclusion)

List of Eligible Countries

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Afghanistan Malawi

Angola Mali

Bangladesh Marshall Islands

Benin Mauritania

Bhutan Mauritius

Botswana Mongolia

Burkina Faso Mozambique

Burma Myanmar

Burundi Namibia

Cambodia Nepal

Cameroon Niger

Cape Verde Islands Nigeria

Central African Republic North Korea

Chad Pakistan

Comoros Islands Palau

Congo Papua New Guinea

Democratic People's Republic of Korea Philippines

Democratic Republic of Congo Republic of Korea

Djibouti Republic of Moldova

East Timor Republic of Moldova

Equatorial Guinea Rwanda

Eritrea Sao Tome and Principe

Ethiopia Senegal

Federated States of Micronesia Seychelles

Gabon Sierra Leone

Gambia Somalia

Ghana South Africa

Greenland South Korea

Guinea Bissau Sudan

Guinea Republic Swaziland

Haiti Tajikistan

India Tanzania

Indonesia Timor-Leste

Ivory Coast Togo

Kenya Tuvalu

Kiribati Uganda

Laos Vietnam

Lesotho Zambia

Liberia Zimbabwe

Madagascar